Commentary: My Prescription for the Prescription Drug Abuse Epidemic

I am an emergency physician. It is the best job in the world and I am proud to do it. However, recent media reports paint my colleagues and me as the source behind the recent dramatic rise in prescription drug abuse. We aren’t. Despite certain perceptions to the contrary, we actually account for a very low percentage of all narcotics prescribed.

ACEP- chart

Key: IR = immediate release; ER/LA = extended release/long-acting; EM = emergency medicine

  • General Practitioner/Family Practitioner/Doctor of Osteopathy and Internal Medicine were the top  prescribers for immediate release and long-acting opioids
  • Immediate-release opioid prescribers:
    • Dentists and emergency medicine specialists accounted for about 7.7 percent and 4.7 percent of all immediate-release prescriptions for opioids

Source:  U.S. Food and Drug Administration:  Presentation: Outpatient Prescription Opioid, Utilization in the U.S., Years 2000 – 2009, July 22, 2010

Even when we write narcotic prescriptions, we do so for a limited supply, knowing our acute pain patients will need to follow up with other physicians for more definitive treatment.

Precisely because we are on the front lines of the battle against this scourge every single day, emergency physicians have a vested interest in keeping unnecessary prescription drugs off the streets. The number of emergency department visits related to prescription drugs now exceeds those from cocaine and methamphetamine abuse combined. We see the tragedies and the near-tragedies of this epidemic every day in our ERs. The victims are never just the patients who have overdosed – every one of them has family and friends who are negatively affected by the damage and deaths caused by prescription drug abuse.

Our challenge as emergency physicians is to strike the balance between providing needed pain control and keeping the public safe.

For that reason, we employ a variety of techniques, from checking government databases to good old clinical judgment to separate those who need narcotic analgesia from those who may be seeking these drugs for purposes of abuse. Studies demonstrate that emergency physicians are actually quite good at making these determinations.

But there are still significant challenges to curbing our nation’s addiction to prescription narcotics. First and foremost, even when addiction is proven there are very few resources to aid in recovery (assuming that the addicted patient is ready to begin that process).

Second, significant pressure is placed on emergency physicians to improve customer satisfaction. Some physicians are docked pay or even fired based on the results of patient satisfaction surveys. When challenging a patient regarding their drug-seeking behavior it is not uncommon to hear a retort of “I’m going to give you a bad survey” or “I’m calling the hospital’s complaint line.” If the physician faces the loss of pay or even the job over a “bad survey,” how are they likely to respond? What would you do?

This “customer satisfaction” focus creates a significant disincentive for emergency physicians to hold fast against the onslaught of drug seekers. We have significant powers of persuasion with our patients, but there are always those determined addicts who will stop at nothing to feed their addiction. Every emergency physician has treated them.

So what can be done? First, we need to improve access to primary care providers so that patients with chronic painful conditions can be managed in a consistent manner. Second, we need to allow emergency physicians to refer chronic pain patients to their primary care providers without prescriptions for narcotic medications and without repercussions from the dreaded “surveys.”

Lastly, we need to improve access to mental health and addiction recovery services, so that we can provide addicted patients the assistance they really need instead of the drugs they want.

Howard Mell, MD, FACEP
Emergency physician
American College of Emergency Physicians

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    Joe Smith

    July 29, 2013 at 8:09 AM

    I’m glad someone finally stood up for the doctors and quit using them as the fall guys for the prescription drug problem in this country!

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    July 26, 2013 at 6:52 PM

    Actually, it was my surgeon who offered me Vicodin when he couldn’t figure out what was wrong with me. The CT Scan didn’t show the hernia that was tearing inside me, so he dismissed the option of having surgery and just offered me narcotics instead.

    Well, I got out of there and got myself a new surgeon who did the surgery and fixed the hernia. He offered me Vicodin “post” surgery and I took 2 of them before discarding them.

    ER doctors have fed my son Vicodin and he’s an addict in recovery. What will it take to get doctors to understand how many millions are addicted to Vicodin and subsequently Oxycontin?

    Yes doctors YOU are the problem.

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    Dr. John Gardin

    July 26, 2013 at 3:27 PM

    I agree with Dr. Mell’s assessment of prescription drug abuse and prescribers. But his “first and foremost” comment is a myth. This belief that resources don’t exist for recovery from substance misuse is quite simply not true. The facts are that the vast majority of individuals with substance misuse issues are looking for treatment and don’t want treatment. Those seeking recovery resources in all but the most rural and isolated settings find it, including self-help groups (both local meetings and online) and treatment programs.

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    July 23, 2013 at 3:35 PM

    I have worked in Addictions and Mental Health since 1988. Far and away the biggest provider of prescriptions that my patients and clients have abused over the years have been family doctors. Many had no idea that said prescriptions were being abused and others never asked the important questions. I found that ER nurses and Drs are far more knowledgable about the abuse of substances. They also tend to be more conservative in their use of medications. All medical and nursing professionals – and all healthcare professionals in general could do with continuing education about addictions so they can better respond to situations they face on a daily basis. Like Mental Health clients, those struggling with Addictions still face a lot of stigma and a lot of that is at the hands of their healthcare providers because of their lack of current knowledge and training.

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    Perry Kaplan

    July 23, 2013 at 1:31 PM

    Dr. Mell is correct that emergency room physicians are not the cause of the prescription drug epidemic (though I have rarely heard them so accused). The answer, however is not to allow them to send patients who need them out without pain meds–that’s abdicating their responsibility–the answer is to stop criminalizing a public health problem and believing that we can solve the problem of addition by regulating doctors. 50 years into the “War on Drugs” and this country has learned nothing. You can solve diabetes by outlawing sugar; you can’t solve addiction by outlawing drugs. But we can support a huge, expensive military and police force to incarcerate low level drug dealers–now there’s a policy that makes a lot sense–as long as you own stock in a gun manufacturer or private corrections company.

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